Untitled Flashcards Set

Mid Term Review

WEEK 1

Nursing Process: organized framework for professional nursing practice

Assessment

-       Nursing assessment/health history. Physical assessment, medical records, diagnostic test results

Diagnosis (Nursing diagnosis not medical)

-       Problem (nursing diagnosis)

-       Etiology- write an r/t (related to) phrase

-       Signs and symptoms

Planning (outcomes and interventions)

Implementation

Evaluation

Objective Data: Observable and measurable data that can be seen, heard, or felt by someone

Subjective Data: Information perceived by the patient (Pain, dizzy, anxious, etc.)

3 types of nursing diagnosis

-       Problem focused (3 part)

o   Problem (label) + Etiology + symptoms

o   Undesirable response to health condition/process

-       Risk Diagnosis (2 part)

o   Potential problem (risk for) +Etiology

o   Vulnerable to having an undesirable response

-       Health promotion diagnosis

o   Focus is on being healthy

o   Focus is NOT preventing an illness

WEEK 2

Chapter 24: Middle and Older Adulthood

Physiologic Changes of Oder adults

-       General, integumentary, musculoskeletal, neurologic, cardiopulmonary, gastro, dentition, genitourinary

Vitals Ranges

-       Oral temp: 96.4-99.5

-       Pulse- 60 to 100 (80 average)

-       Respirations – 12 to 20

-       BP- 120/80

Fever

-       Afebrile – w/o fever

-       Pyrexia- with fever (febrile)

-       Intermittent fever- temp returns to normal at least once every 24 hrs

-       Remittent fever- temp does not return to normal. Flucturales a few degrees up and down

-       Sustained/continuous fever- temp remains above normal w/minimal variations

-       Relapsing/recurrent fever- temp returns to normal for 1+ days w/1 or nore episdoes of fever

-       Oral: 35.9–37.5°C; 96.6–99.5°F

-       Rectal: 36.3–38.1°C; 97.4–100.5°F

-       Axillary: 35.4–36.9°C; 95.6–98.5°F

-       Tympanic: 36.8–38.3º C; 98.2–100.9°F

-       Forehead (temporal artery): 36.3–38.1°C; 98.7–100.5°F

Pulse

·      Parasympathetic: decrease heart rate

·      Sympathetic: increases heart rate

·      Pulse rate: # of contractions over a peripheral artery in 1 minute

o   Volume of blood ejected w/each heartbeat (stroke volume)

Pulse strength (amplitude)

·      Grade 0= absent, unable to palpate

·      Grade +1 = diminished, weaker than expected

·      Grade +2 = normal; brisk, expected

·      Grade 3+ = bounding

Diffusion: exchange of O2 and CO2 between alveoli of lungs and blood

Perfusion: exchange of O2 and CO2 between blood and tissue cells

Hypotension: <90/60

Orthostatic hypotension (postural)

-       Dehydration, blood loss, problem of neurologic, cardio, endocrine

Chapter 27: health assessment

Types

-       Comprehensive: conducted upon admission to health care facility

-       Ongoing partial: conducted at regular intervals

-       Focused: conducted to assess a specific problem

-       Emergency: conducted to determine life threatening/unstable conditions

Awareness: time, place, person, situation

WEEK 3

Chapter 3: health wellness

Health- a state of complete physical, mental, and social well-being

Wellness- an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health

Health equity: highest level of health for all people

Risk factors for illness and injury:

-       Age, genes, physiologic, health habits, lifestyle, environment

Chapter 5: culturally respectful care

Culture: shared system of beliefs, values, and behavioral expectations

Subculture: large group of people who are members of a larger cultural group

Chapter 8: Communication

Understand SBAR

Phases of therapeutic relationship

-       Orientation phase

-       Working phase

-       Termination phase

-        

Chapter 9: Teaching and Counseling

Factors affecting patient learning

-       Age/developmental level, family/caregiver support networks, financial resources, cultural influences, health literacy

Cognitive: storing and recalling of new knowledge in the brain

Psychomotor: learning a physical skill involving the integration of mental and muscular activity

Affective: changing attitudes, values, and feelings

 Methods of teaching

-       Lecture, discussion, panel, demonstration, discovery, role playing

Cognitive domain: lecture, panel, discovery, written materials

Affective domain: role modeling, discussion, audiovisual materials

Psychomotor domain: demonstration, discovery, printed materials

Documentation: a summary of the learning need -> plan -> implementation of the plan -> evaluation results

WEEK 4 and 5

Chapter 33: Skin integrity and Wound care

Function of the skin

-       Protect, body temp, psychosocial, sensation, vitamin D, immunologic, absorption/elimination

Age <2= skin is thinner and weakier

Older adults: circulation and collagen formation are impaired-> decreased elasticity

Phases of wound healing

-       Hemostasis

o   Occurs immediately after injury

o   Blood vessels constrict- > clotting begins-> swelling, pain,heat,redness

-       Inflammatory

o   2-3 days, WBC move to wound

-       Proliferation

o   Several weeks, tissue is built to fill wound space

-       Maturation

o   3 wks after injury->collagen remodeled, scar

Desiccation: dehydration

Maceration: overhydration

Necrosis: tissue death

Presence of biofilm: thick grouping of microorganisms

Wound complications: infection, hemorrhage, dehiscence and evisceration, fistula formation

-       Evisceration: bowel falling out of wound

Stages of Pressure Injuries

Stage 1: non-blanchable erythema of intact skin

Stage 2: partial-thickness skin loss with exposed dermis

Stage 3: full-thickness skin loss; not involving underlying fascia

Stage 4: full-thickness skin and tissue loss

Unstageable: obscured dull-thickness skin and tissue loss

Deep tissue: deep red, maroon, purple discoloration

Wound drainage types

-       Serous

-       Sanguineous

-       Serosanguineous

-       Purulent

Braden Scale: Sensory perception, moisture, activity, mobility, nutrition, friction and shear

Cleaning a pressure injury/wound

-       0.9% ns solution to irrigate/clean

-       R = red-protect/ Y = yellow- cleanse/ B= black-debride

Applying heat

-       Dilates peripheral blood vessels

-       Reduces muscle tension-> helps relieve pain

Applying cold

-       Constricts peripheral blood vessels

-       Reduce muscle spasms ->promotes comfort

Chapter 38: Urinary Elimination

Diuretics: prevent reabsorption of water and certain electrolytes in tubules

Cholinergic medications: stimulate contraction of detrusor muscle, making pee

Analgesics/tranquilizers: suppress CNS, diminish effect of neural reflex

Medications affecting color of urine

Anticoagulants: red urine

Diuretics: pale yellow urine

Pyridium: orange to orange-red urine

Antidepressant amitriptyline/B-complex: green or blue-green urine

Levodopa: brown or black urine

Physical assessment of urinary functioning

-       Kidneys, bladder, urethral orifice, skin, urine

Urinary incontinence

·      Transient: appears suddenly and lasts 6 months or less

·      Mixed: urine loss w features of two or more types of incontinence

·      Overflow: overdistention and overflow of bladder

·      Functional: caused by factors outside w/urinary tract

·      Reflex: emptying of the bladder w/o sensation of need to void

·      Total: continuous, unpredictable loss of urine

·      Stress: involuntary loss of urine related to an increase in intraabdominal pressure

Types of Catheters

·      Indwelling catheter

o   Critically ill patients: assists in healing open sacral or perineal wounds in incontinent patients

o   Prolonged patient immobilization

·      Intermittent/suprapubic

Chapter 39: Bowel elimination

Bowel sounds: hypoactive, hyperactive, absent, infrequent

Stool collection: medical aseptic

·      Volume

·      Color

·      Odor

·      Consistency/shape

High risk constipation: bedrest, medicine, reduced fluids, depressed, CNS disease

Nasogastric tubes: inserted to decompress/drain the stomach of fluid or unwanted stomach contents

Types of ostomies (5)

-       Sigmoid, descending, transverse, ascending, ileostomy

-        

Chapter 40: oxygen and perfusion

Properly functioning alveolar system in lungs

-       Oxygenates venous blood

-       Removes carbon dioxide from blood

Properly functioning cardio and blood supply

-       Carry nutrients and wastes to/from body cells

Hypoxia: inadequate amount of o2 available to the cells

Dyspnea: difficulty breathing

Hypoventilation: decreased rate/depth of air movement into the lungs

Alterations in the cardio system

-       Dysrhythmia/arrhythmia

-       Myocardial ischemia

-       Angina

-       Myocardial infarction

-       Heart failure

Respiratory functioning in the older adult

-       Bondy landmarks: more prominent due to loss of subq fat

-       Kyphosis: contributes to appearance of leaning forward

-       Barrel chest: result in increased anteroposterior diameter

Normal breath sounds

Vesicular: low pitched, soft sound during expiration

Bronchial: high pitched and longer, heard primary over the trachea

Bronchovesicular: medium pitch and sound during expiration, heard over the upper anterior chest/intercostal area

Types of artificial airways

-       Oro/nasopharyngeal

-       Endotracheal/tracheostomy

Supplemental O2

-       Nasal canula – high or low

-       Simple mask

-       Norebreather

-       Venturi mask

Chapter 41: Fluid and electrolyte balance

Intracellular fluid: fluid within cells (70%)

Extracellular fluid: fluid outside cells (30%)

Healthy person: total body water is 50-60% of weight

Solvents: liquids that hold a substance in solution (water)

Solutes: substances dissolved in a solution (electro/nonelectrolytes)

Fluid imbalances

Hypovolemia: deficiency in amt of water and electrolytes in ecf

Third-space fluid shift: distributional shift of body fluids into potential body spaces

Osmosis: water passes from an area of lesser solute concentration to greater until equilibrium is established       

Isotonic: 0.9% NS, lactated ringer

Hypertonic: 3% NS

Hypotonic: 0.45% NS, D5W

Acidosis- excess hydrogen ions

Alkalosis- loss of hydrogen ions       

Fluid Volume Excess

Hypervolemia: excessive retention of water and sodium in ECF

Respiratory acidosis/alkalosis: carbonic acid

Metabolic acidosis/alkalosis: bicarbonate

Chapter 45: Sensory Functioning

-       Visual, auditory, olfactory (smell), gustatory (taste), tactile (touch), stereognosis (perception of solidity of objects)

Chapter 6: Values, ethics, and Advocacy

Professional Values

Altruism: concern for welfare and well-being of others

Human dignity: respect for worth and uniqueness of individuals/populations

Integrity: acting according to code of ethics and standards of practice

Social justice: upholding moral, legal, and humanistic rights

Principle based Approach to Bioethics

Autonomy: respect rights of patients to make healthcare decision

Nonmalefience: avoid causing harm

Beneficence: benefit the patient

Justice: give each their due and act fairly

Fidelity: keep promises

Veracity:

Moral agency: the capacity to be ethical and do the ethically right thing for the right reasons      

Moral distress: when you know the right thing to do, but either personal or other factors make it difficult to follow the right course of acotion

Moral resilience developed capacity to respond well to morally distressing experiences and to emerge strong